| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
325 |
323 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
294 |
290 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
267 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
176 |
$3K |
| D0274 |
Bitewings - four radiographic images |
101 |
101 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
13 |
$593.89 |
| D1206 |
Topical application of fluoride varnish |
55 |
55 |
$311.21 |
| D2740 |
Crown - porcelain/ceramic |
26 |
14 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
29 |
$0.00 |